Method for continuous measurement of flux of gases in the lungs during breathing

ABSTRACT

A method of calculating the flux of any gas (x) in a CBC circuit for a ventilated or a spontaneous breathing subject, for example said gas(x) being; a) an anesthetic such as but limited to; i)N 2 O; ii) sevoflurane; iii) isoflurane; iv) halothane; v) desflurame; or the like b) Oxygen; c) Carbon dioxide; or the like utilizing the following relationships; Flux of gas(x)=SGF (F SX −F EX ) wherein SGF=Source of gas flow into the breathing circuit (CBC circuit) in liters/minute as read from the gas flow meter as set by the anesthesiologist; F SX =Fractional concentration of gas X in the source gas (which is set by the anesthesiologist); F EX =Fractional concentration of gas X in the end expired gas as determined by a portable gas analyzer, or the like.

FIELD OF INVENTION

This invention relates to a method of measuring uptake and elimination via the lung of all gases for example including, but not limited to, anesthetics, oxygen and carbon dioxide.

BACKGROUND OF THE INVENTION

The following represents a glossary of terms used within the specification. The reader is referred to these definitions when interpreting the meaning of any description herein.

-   1) {dot over (V)}E: minute ventilation (the total volume of gas     breathed in and out of the lung per minute). PETCO₂: end tidal PCO₂     (the partial pressure of CO₂ at end exhalation); -   2) SGF: source gas flow (the flow of gas into a breathing circuit,     in liters/min); -   3) {dot over (V)}A: alveolar ventilation (that ventilation that     results in gas exchange between the pulmonary capillaries and the     air spaces (alveoli) of the lung), expressed in liters/min. It is     also defined as the total ventilation minus the ventilation of the     anatomic dead space ({dot over (V)}E-{dot over (V)}Dan); -   4) {dot over (V)}O₂: The O₂ consumed in liters per minute; -   5) {dot over (V)}CO ₂: The CO₂ produced in liters per minute; -   6) FSx: fractional concentration of a gas x in source gas (gas     entering a breathing circuit); -   7) FIx: fractional concentration of gas x in inspired gas (gas     entering the patient's lungs); -   8) FEx: the fractional concentration of gas x in end expired gas; -   9) CBC (conditional breathing circuit): a breathing circuit in which     only exhaled gas, and no source gas, exits from the circuit, as     would be the case with a circle circuit with a low flow of gas     entering the circuit, or a Magill circuit in which a) SGF is     ≦0.7×{dot over (V)}E; b) the common breathing tube volume (see     FIG. 1) is greater than or equal to the sum of [(SGF×expiratory     time)+the anatomical dead space]; c) the volume of the breathing bag     is greater than [the largest expected tidal volume−(SGF×inspiratory     time)].     Introduction

The measurement of uptake and elimination of gases via the lungs plays an important role in medicine. Oxygen consumption ({dot over (V)}O₂) and CO₂ production ({dot over (V)}CO ₂) are two important parameters indicating cardio-respiratory fitness of athletes. {dot over (V)}O₂ and {dot over (V)}CO ₂ are also used as important indicators of the efficacy of therapeutic intervention in critically ill patients. The ability to impose a transient change in {dot over (V)}O₂ and {dot over (V)}CO ₂ allows one to calculate such important physiological parameters as cardiac output and functional residual capacity. For the most part, anesthesia is induced and maintained by gases taken up by and eliminated from the body via the lungs. Accurate measurement and control of uptake and elimination of anesthetic gases would improve the control of anesthetic depth and thereby the effectiveness and efficiency of the use of anesthetic gases. Accurate control of uptake and elimination of therapeutic gases would allow more controlled dosing when these gases are used as therapies for illness. Accurate control of uptake and elimination of inert gases via the lung can be used for various diagnostic and research purposes.

Present Art

Measuring Gas Flux

Measuring total gas flux requires the measurement of gas volumes for discrete periods of time and multiplying these volumes by the concentration of the gas in the volume.

Volume Measurements

Measurement of exhaled gas volumes is very cumbersome in clinical or research settings. One method requires timed collections of exhaled gas in bags and then measuring the volume of the bags. Inhaled volumes are even more awkward to measure continuously as the volumes enter the lung and one must measure the volume of lung expansion or the volume depleted from a previously known volume. This cannot be done breath-by-breath. These measurements are usually simplified by measuring flow continuously at the mouth and integrating the flow electronically with respect to time to obtain “continuous” measures of volume. Each type of flow measuring device has inherent problems leading to inaccuracy of calculation of volume (see below).

Flux Measurements

To measure the flux of a particular constituent (gas x) of the total gas that enters or exits the lung is more complex. The concentration of x sampled at the mouth during breathing changes between inhalation and exhalation as well as continuously during each ventilatory phase. Therefore, to measure the flux of gas x, the concentration of gas x must be measured continuously with a rapidly responding gas analyzer, and the average concentrations over short intervals must be multiplied by the volume changes over those same intervals. This requires synchronization of flow-volume signals and gas concentration signals, then multiplying the values and continuously summing them. A number of devices on the market such as the Vmax (Sensormedics, Yorba Linda Calif.), Medical Graphics CPOX/D, (Medical Graphics Corporation, St. Paul, Minn.) and NICO (Novametrix, Wallingford, Conn.) measure the fluxes of CO₂ and/or O₂ at the mouth using this method. The same principles apply to measuring the flux of other gases if appropriate gas sensors are used.

Measuring Gas Fluxes During Anesthesia

a) Understanding the Anesthetic Circuits

One circuit used for anesthesia is the Magill circuit with the Mapleson A configuration illustrated in FIG. 1 (“Magill circuit”). The patient breathes through the patient port (30). During inhalation, gas is drawn from the source gas port (33) and the gas reservoir bag (34) along the common breathing tube (32). Expiration is divided into two phases. The first phase lasts from the beginning of exhalation until the filling of the gas reservoir bag (34). During this first phase of exhalation, expired gas proceeds down the common breathing tube (32) with gas from the anatomical dead space preceding gas from the alveoli. Expired gas displaces gas in the breathing tube (32) into the gas reservoir bag. During his phase of exhalation the source gas is also directed into the gas reservoir bag. The second phase of exhalation is from the time of filling of the gas reservoir bag (34) until the beginning of inhalation. During this second phase of exhalation, the expired gas exits through the one way pressure relief valve (31) that has an opening pressure of about 2 cm H₂O and the source gas proceeds along the common breathing tube (32) displacing gas before it and forcing it out of the pressure relief valve such that the last exhaled (alveolar gas) exits the valve first.

Kain and Nunn (Kain M. L., Nunn J. F. Anesthesiology. 29: 964-974, 1968) determined the minimum source gas flow required to prevent rebreathing in anesthetized patients breathing through the circuit by sequentially decreasing the source gas flow until minute ventilation and end tidal PCO₂ increased. It is generally accepted that the source gas flow needed to prevent rebreathing of alveolar gas is 70% of the minute ventilation ({dot over (V)}E) (Understanding Anesthesia Equipment by Dorsch J. A., and Dorsch S. E., Williams & Wilkins Co. 1975, pg. 169). The 30% savings in source gas is due to the rebreathing of the anatomical dead space gas which does not undergo gas exchange in the alveoli and therefore retains the same composition as source gas.

The 30% savings in source gas flow with the Magill breathing circuit represents the maximum efficiency available for source gas without the use of a CO₂ absorber. As the cost of anesthesia varies directly with the flow of source gas, circuits with CO₂ absorbers, the most popular being the “circle circuit” depicted in FIG. 2, allows a marked reduction in source gas flow (SGF) without causing a rise in end tidal PCO₂. The balance of {dot over (V)}E is provided by rebreathing of previously exhaled gases and the CO₂ absorber (6) prevents the build-up of CO₂ in the circuit and the patient. As not all of the delivered anesthetic is extracted during a breath, exhaled gas has a considerable concentration of anesthetic that can be re-supplied to the patient when rebreathed. The circle circuit contains a patient port (1), and an expiratory limb (2) leading to a one way expiratory valve (3). Distal to the valve there is a flexible gas reservoir (4), a pressure relief valve (5) where excess expired gas is vented, and a container for CO₂-absorbing crystals (6). When the patient inhales, he draws fresh gas entering the fresh gas inlet (7) and makes up the balance of inspired gas by drawing gas from the gas reservoir through the CO₂-absorber. The source gas and the previously exhaled gas join to flow through the one-way inspiratory valve (8) to the patient through the inspiratory limb (9). When the patient exhales, gas passes down the expiratory limb of the circuit (2), past the expiratory valve (3), and enters the flexible gas reservoir (4). When the gas reservoir fills to capacity, pressure in the circuit increases and the pressure relief valve (5) opens, releasing gas to atmosphere during the remainder of exhalation. During exhalation, fresh gas entering the circuit (7) is displaced back into the CO₂ absorber (6). This fresh gas enters the inspiratory limb (9) and is made available to the patient on subsequent breath(s).

The depletion of O₂ and anesthetic from the circuit is prevented by re-supplying both gases through the fresh gas inlet (7). The anesthesiologist can control the total flow of gas as well as the concentrations of all its constituent components such as oxygen, nitrous oxide and anesthetic agent. The minimum gas flow into the circuit is that needed to replace the oxygen consumed and anesthetic absorbed by the body. The CO₂ absorbers extract only CO₂, allowing other gases to pass through unchanged.

b) Calculation of Uptake or Elimination of Gases with Rebreathing Circuits (Present Art):

When a subject breathes via a Magill, circle, or Fisher isocapnia (rebreathing and non-rebreathing) circuit, and the SGF entering the circuit is equal to or greater than {dot over (V)}E, the circuit acts like a nonrebreathing circuit, i.e., inspired concentration of gas x is that of the SGP, i.e., FSx. When SGF is less than {dot over (V)}E, inspired gas is composed of both SGF and previously exhaled gas in the Magill, circle and Fisher rebreathing isocapnia circuit; and composed of SGF and reserve gas in the Fisher non-rebreathing isocapnia circuit. As a result, the concentration of x varies throughout inspiration in a complex way depending on {dot over (V)}E, pattern of breathing, and SGF. To measure the inspired volume of x, inspiration must be broken up into small intervals during which the total volume must be multiplied by the average concentration of x; the resulting discrete volumes of x must be summed for the duration of inspiration. Similarly, to calculate the expired volume of x, continuous measurements of expired flows and expired concentrations of x are required. The net uptake or elimination of x over a given time is the algebraic sum of the inhaled and exhaled volumes of x during that time.

REFERENCE LIST

-   1. Kain M L, Nunn J F. Fresh gas economics of the Magill Circuit.     Anesthesiology 1968; 29(5):964-74. -   2. Wissing H. Kuhn I, Rietbrock S, Fuhr U. Pharmacokinetics of     inhaled anaesthetics in a clinical setting: comparison of     desflurane, isoflurane and sevoflurane [see comments]. Br. J     Anaesth. 2000; 84(4):443-9. -   3. Rietbrock S, Wissing H, Kuhn I, Fuhr U. Pharmacokinetics of     inhaled anaesthetics in a clinical setting: description of a novel     method based on routine monitoring data [see comments]. Br. J     Anaesth. 2000; 84(4):437-42. -   4. Bouillon T, Shafer S L. Hot air or full steam ahead? An empirical     pharmacokinetic model of potent inhalational agents [editorial;     comment] [published erratum appears in Br J Anaesth 2000     June;84(6):833]. Br. J Anaesth. 2000; 84(4):429-31.

It is an object of this invention is to provide a simpler and more accurate method of measuring uptake and elimination via the lung of all gases for example including, but not limited to, anesthetics, oxygen and carbon dioxide.

It is a further object of this invention is to provide a method of controlling gas flux (defined as uptake or elimination from the lung) independent of minute ventilation.

Further and other objects of the invention will become apparent to those skilled in the art when considering the following summary of the invention and the more detailed description of the preferred embodiments illustrated herein.

SUMMARY OF THE INVENTION

According to a primary aspect of the invention we provide a method of measuring the flux of any gas by utilizing SGF times expired concentration of that gas. This is especially applicable in the operating room where all of the equipment required to provide the necessary information is already in use: the circuit, the SGP flowmeters, the gas sensors.

The ability to make a step change in {dot over (V)}A via a change in SGF or FSx can be used to obtain a control measurement of {dot over (V)}A as well as cardiac output by two different methods, the Gideon method and the Fisher method. This proffers marked advantages on these methods with respect to versatility, cost, and accuracy.

The method relates to the novel application of known circuits for measurements of gas flux. Further three new circuits that allow the use of the method outside the operating room in ventilated patients/subjects are also provided, a) the Magill configured for controlled ventilation; b) the rebreathing isocapnia circuit configured for controlled ventilation; and c) the balloon valve circuit.

With reference to the gas input the following conditions apply/result:

-   -   Breathing via a circuit in which the total flow of gas entering         the circuit is less than or equal to the subject's alveolar         ventilation,     -   The balance of gas inhaled is composed of gas that has         substantially the same concentration of gas x as is in the         alveoli of the lung     -   This gas may actually be previously exhaled gas that has been         stored and made available to be rebreathed, or it may come from         an external gas source in which the concentration of x is         substantially the same as that in the alveoli of the lung     -   The input gas flow and concentration of x in input gas are known         and determined by the user

The continuous measurement of expired gas concentrations is possible by utilizing a convenient gas analyzer. Based on the known values therefore that will be further described herein after;

-   -   The rate of elimination of gas x=SGF×(FEx−FSx) for any CBC         circuit as described herein.     -   The rate of elimination of gas x=the input total gas         flow×(FEx−FIx), where Fix is the concentration of x in inspired         gas     -   Gas input parameters     -   Breathing via a circuit in which the total flow of gas entering         the circuit is less than or equal to the subject's alveolar         ventilation,     -   The balance of gas inhaled is composed of gas that has         substantially the same concentration of gas x as is in the         alveoli of the lung     -   This gas may actually be previously exhaled gas that has been         stored and made available to be rebreathed, or it may come from         an external gas source in which the concentration of x is         substantially the same as that in the alveoli of the lung     -   The input gas flow and concentration of x in input gas are known         and determined by the user

According to one aspect of the invention there is provided a method of calculating the flux of any gas(x) in a CBC circuit for a ventilated or a spontaneous breathing subject,

-   -   for example said gas(x) being;     -   a) an anesthetic such as but limited to;         -   i) N₂₀;         -   ii) sevoflurane;         -   iii) isoflurane;         -   iv) halothane;         -   v) desflurame;     -   or the like     -   b) Oxygen;     -   c) Carbon dioxide;     -   or the like     -   utilizing the following relationships;         Flux of gas(x)=SGF(F _(SX) −F _(EX))         wherein     -   SGF=Source of gas flow into the breathing circuit (CBC circuit)         in liters/minute as read from the gas flow meter as set by the         anesthesiologist;     -   F_(SX)=Fractional concentration of gas X in the source gas         (which is set by the anesthesiologist);     -   F_(EX)=Fractional concentration of gas X in the end expired gas         as determined by a portable gas analyzer, or the like.

According to another aspect of the invention there is also provided a method of calculating the flux of oxygen in a CBC circuit for a ventilated and/or spontaneous breathing subject utilizing the following relationship; Flux of oxygen=SGF(F _(SO2) −F _(EO2))

-   -   wherein     -   SGF=Source of gas flow into the breathing circuit (CBC circuit)         in liters/minute as read from the gas flow meter as set by the         anesthesiologist;     -   F_(SX)=Fractional concentration of gas O₂ in the source gas         (which is set by the anesthesiologist);     -   F_(EX)=Fractional concentration of gas O₂ in the end expired gas         as determined b)_(y) a portable gas analyzer, or the like.

In one embodiment for the abovementioned methods the CBC circuit is selected from the group consisting of i) a circle circuit; ii) a Magill breathing circuit; iii) an isocapnia circuit, whether breathing or non-breathing (as taught by co-pending Fisher et al), or the like.

In another embodiment for the abovementioned methods the CBC circuit is an improved Magill circuit as described herein.

In yet another embodiment for the abovementioned methods the CBC circuit is an improved rebreathing circuit as described herein.

In yet another embodiment for the abovementioned methods the CBC circuit is an improved non-rebreathing circuit as described herein.

Preferably in yet another embodiment the abovementioned methods are used to determine oxygen consumption in order to measure cardiac out put by any known method, such as the Fick method.

Preferably in yet another embodiment the abovementioned methods are used to determine oxygen consumption in, for example, an operating room setting or the like. Preferably in yet another embodiment the abovementioned methods are used to optimize oxygen consumption. Preferably the abovementioned methods are utilized as an early indication of malignant hyperthermia.

According to yet another aspect of the invention there is provided a method of calculating the flux of any gas other than carbon dioxide, in a CBC circuit with low gas flow of source gas and with a carbon dioxide absorber in place utilizing the following relationship; Flux of gas X=SGP(FEX−FRBX)

-   -   wherein     -   SGF=Source of gas flow into the breathing circuit (CBC circuit)         in liters/minute as read from the gas flow meter as set by the         anesthesiologist;     -   F_(EX)=Fractional concentration of gas X in the end expired gas         as determined by a portable gas analyzer, or the like;     -   F_(RBX)=Concentration of gas X in the expired limb of circuit         before the gas passes through the carbon dioxide absorber and         mixes with gas coming from the flow meter.

Preferably in yet another embodiment the abovementioned methods are used to determine the flux of an anesthetic for example:

-   -   i) N₂₀;     -   ii) sevoflurane;     -   iii) isoflurane;     -   iv) halothane;     -   v) desflurame,     -   or the like

Preferably said methods are used to determine how much anesthetic is being absorbed by the patient. Preferably said anesthetic is N₂O.

According to yet another aspect of the invention there is provided an improved Magill circuit the improvement comprising an inspiratory and expiratory limbs, a pressure relief valve at the end of the expiratory limb, a port for entry of SGF, and a gas reservoir bag, the components of the Magill system utilized for spontaneous ventilation; or alternatively for controlled ventilation, the gas reservoir bag is enclosed in a container with a port for connection to a ventilator breathing circuit, the pressure relief valve being enclosed in a container with a port for connection to a ventilator breathing circuit;

-   wherein on exhalation, the patient breathes out through the patient     port and during the initial part of exhalation, the gas reservoir is     partially empty and the resistance to flow along the inspiratory     limb is less than that of the expiratory limb because the higher     opening pressure of the pressure relief valve must be overcome     before flow can proceed through the expiratory limb, -   wherein during the initial part of expiration, the expired gas     enters the inspiratory limb, displacing gas in the inspiratory limb     and from the SGF into the gas reservoir, as the gas reservoir fills,     the pressure in the circuit increases above the opening pressure of     the pressure relief valve and the remainder of the expired gas is     directed down the expired limb displacing the gas out of the expired     limb through the pressure relief valve to the ventilator breathing     circuit from where it is eventually vented to atmosphere through the     expiratory port and the SGF continues to flow towards the patient     down the inspiratory limb, displacing previously exhaled gas into     the expiratory limb; -   wherein during inhalation, the balloon valve occludes the ventilator     circuit expiratory port and a volume of gas equal to a tidal volume     is delivered by the ventilator into the ventilator circuit and hence     into the SGF gas reservoir box, thereby displacing a volume equal to     the tidal volume from the SGF gas reservoir into the inspiratory     limb of the Magill circuit, the SGF continues to flow towards the     patient down the inspiratory limb; -   wherein the net tidal volume of the patient is equal to the volume     displaced from the gas reservoir plus the SGF multiplied by the     duration of inspiration, because the pressures on both sides of the     Magill pressure relief valve are equal during inspiration, the     differential pressure provided by the “opening pressure” of the     valve keeps it dosed during inspiration;     -   assuming that:     -   (1) the volume of the inspiratory limb is greater than or equal         to [(SGF×expiratory time)+the anatomical dead space]; and the         breathing bag volume is greater than [the largest expected tidal         volume−(SGF×inspiratory time)],     -   (2) SGF is ≦0.7×{dot over (V)}E

According to yet another aspect of the invention there is provided an improved rebreathing isocapnia circuit comprising a Y piece with a patient port, and inspiratory limb of the Y piece with a one way inspiratory valve and an expiratory limb of the Y piece with a one way expiratory valve; the inspiratory limb being connected to a SGP and a gas reservoir, the expiratory limb leading to an expiratory gas reservoir, the expiratory gas reservoir having a one way valve at the port where expired gases are vented from the expired gas reservoir which allows gas to exit the expiratory gas reservoir but not enter, having disposed between the expiratory limb and the inspiratory limb distal to the inspiratory and expiratory valves a bypass limb that contains a one-way valve with an opening pressure of the valve, being for example approximately 1.5 cm H₂O, greater than the valves in the inspiratory limb of the Y piece and the expiratory limb of the Y piece; the direction of opening of the one-way valve in the bypass limb being from the expiratory limb to the inspiratory limb, the inspiratory and expiratory limbs being extended by tubing of variable lengths, the inspiratory and expiratory reservoirs being enclosed in a box with 3 ports; one port communicates with the box, one port communicates with the interior of the SGF reservoir only, one port communicates with the expiratory gas reservoir, the SGF reservoir is continuous with the inspiratory limb of the circuit, the expiratory gas reservoir is continuous with the expiratory limb of the circuit and has a port through which expired gas exits the expired gas reservoir and enters the box, a ventilator, a mushroom valve synchronized to occlude the ventilator circuit expiratory port during the inspiratory phase attached to the box ventilator port such that during the inspiratory phase, the tidal volume of the ventilator is discharged into the box, which will displace an equal volume from the gas reservoirs in the box; as the valve in the bypass limb has a greater opening pressure than the inspiratory valve, the inspiratory reservoir will be compressed in preference to the expiratory reservoir, when the inspiratory reservoir is collapsed, the remainder of the tidal volume will result from compression of the expiratory reservoir and displacement of gas through the bypass limb and valve and inspiratory valve to the patient, the total tidal volume will be equal to the volume displaced from the inspiratory reservoir plus the volume displaced from the expiratory reservoir plus the SGF multiplied by the time during inspiration; during exhalation, the balloon valve is deflated, opening the expiratory port of the ventilator circuit to atmosphere and the expiratory reservoir bag to atmosphere via the port, thus allowing exhaled gas to flow past the expiratory one-way valve down the expiratory lid into the expiratory reservoir, SGF flowing into the port being directed down the inspiratory limb to the SGP reservoir, wherein gas is displaced in the box by expansion of the SGF reservoir and the expiratory gas reservoir is displaced from the box via the ventilator expiratory port; wherein SGF is less than or equal to {dot over (V)}E−{dot over (V)}Dan.

According to yet another aspect of the invention there is provided an improved non-rebreathing circuit, the improvement comprising a balloon valve circuit for spontaneous ventilation of a patient breathing spontaneously, said circuit having a Y piece with a patient port, an inspiratory limb including a balloon valve, connected to SGF and a gas reservoir, an expiratory limb consisting of a balloon valve leading to an expiratory gas reservoir, which has a port opening to the atmosphere, a tank of compressed air flows through solenoid valves to open or close the balloon valves, the solenoid valves being controlled electronically by a computer, a pressure transducer connected to a mouthpiece for measuring when the fresh gas reservoir has been fully collapsed, the computer for receiving the signal and sending a signal to the solenoid valve to dose the inspiratory valve and open the expiratory valve, the fresh gas flow continuously filling the fresh gas reservoir.

Preferably any previous method described herein may be used to calculate the rate of elimination of a gas X for any input total gas flow utilizing the following further relationships;

-   wherein the rate of elimination of gas X=the input total gas flow     (multiplied by) F_(EX)−FI_(X);     -   wherein F_(EX) is defined above and F_(IS) is the concentration         of X in inspired gas.

Preferably said method is incorporated in an algorithm spreadsheet, formula or the like contained within software which is capable of running on a computing device, or is installed therein.

BRIEF DESCRIPTION OF THE DRAWINGS

In the following examples, there are described several preferred embodiments to illustrate the invention. However, it should be understood that the invetin is not intended to be limited to the specific embodiments.

FIG. 1 is schematic diagram of a typical Magill circuit having a Mapleson A configuration.

FIG. 2 is schematic diagram of a typical circle anaesthetic circuit.

FIG. 3 is schematic diagram of an improved Magill circuit having a Mapleson A configuration for controlled ventilation illustrated in one embodiment of the invention

FIG. 4 is schematic diagram of an improved rebreathing isocapnia circuit for spontaneous ventilation illustrated in one embodiment of the invention.

FIG. 5 is schematic diagram of an improved rebreathing isocapnia circuit for controlled ventilation illustrated in one embodiment of the invention.

FIG. 6 is schematic diagram of an an actively controlled rebreathing circuit for controlled ventilation illustrated in one embodiment of the invention.

FIG. 7 is schematic diagram of a non-rebreathing isocapnia circuit for spontaneous ventilation illustrated in one embodiment of the invention.

FIG. 8 is schematic diagram of a non-rebreathing isocapnia circuit for controlled ventilation illustrated in one embodiment of the invention.

FIGS. 9A and 9B illustrate diagrams of flow and integrated concentration curves for carbon dioxide.

FIG. 10 illustrates with 95% confidence intervals the comparison of measurements of {dot over (V)}CO₂for the method of the present invention and the Douglas Bag collection method and differences between those measurements.

FIG. 11 illustrates a comparison of {dot over (V)}CO ₂ for the standard bag collection method, a metabolic cart and the method of the present invention.

DETAILED DESCRIPTION OF EMBODIMENTS OF THE INVENTION

The reader is referred generally to the figures with regard to the following description of various embodiments of the invention.

Our Improved Method:

Circuit:

-   -   a) A rebreathing circuit in which only exhaled gas and no source         gas exits from the circuit, as would be the case with         -   i) a circle circuit,             -   (1) patient breathing spontaneously or mechanically                 ventilated,             -   (2) SGF much less than {dot over (V)}E, for example SGP                 is less than half of {dot over (V)}E,         -   ii) Magill circuit             -   (1) Patient breathing spontaneously             -   (2) Ventilated patients: The Magill circuit (FIG. 1) was                 designed for spontaneously breathing patients only as it                 was felt that the efficiencies of the circuit vis a vis                 conservation of SGF could not be obtained with                 manual-assisted or mechanical ventilation (1). We                 describe a modification of the Magill breathing circuit                 that will provide all of the benefits with respect to                 calculation of gas flux during mechanical ventilation.                 The circuit (FIG. 3) consists of a Y-piece (47) with an                 opening to the patient (35) and inspiratory (38) and                 expiratory (36) limbs, a pressure relief valve at the                 end of the expiratory limb (37), a port for entry of SGF                 (39), and a gas reservoir bag (40)—components of the                 Magill system used for spontaneous ventilation. For                 controlled ventilation, the gas reservoir bag (40) is                 enclosed in a container with a port (44) for connection                 to a ventilator breathing circuit. The pressure relief                 valve (37) is enclosed in a container (48) with a port                 for connection to a ventilator breathing circuit.                 -   On exhalation, the patient breathes out through the                     patient port (35). During the initial part of                     exhalation, the gas reservoir (40) is partially                     empty and the resistance to flow along the                     inspiratory limb (38) is less than that of the                     expiratory limb (36) because the higher opening                     pressure of the pressure relief valve (37) must be                     overcome before flow can proceed through the                     expiratory limb (36). Therefore, during the initial                     part of expiration, the expired gas enters the                     inspiratory limb (38), displacing gas in the                     inspiratory limb (38) and from the SGF (39) into the                     gas reservoir (40). When the gas reservoir (40)                     fills, the pressure in the circuit increases above                     the opening pressure of the pressure relief valve                     (37) and the remainder of the expired gas is                     directed down the expired limb (36) displacing the                     gas out of the expired limb through the pressure                     relief valve (37) to the ventilator breathing                     circuit from where it is eventually vented to                     atmosphere through the expiratory port (49). The SGF                     continues to flow towards the patient down the                     inspiratory limb (38), displacing previously exhaled                     gas into the expiratory limb (36).                 -   During inhalation, the balloon valve (43) occludes                     the ventilator circuit expiratory port (49) and a                     volume of gas equal to a tidal volume is delivered                     by the ventilator (42) into the ventilator circuit                     (46) and hence into the SGF gas reservoir box (41),                     thereby displacing a volume equal to the tidal                     volume from the SGP gas reservoir (40) into the                     inspiratory limb of the Magill circuit (38). The SGF                     continues to flow towards the patient down the                     inspiratory limb (38). The net tidal volume of the                     patient is equal to the volume displaced from the                     gas reservoir (40) plus the SGF multiplied by the                     duration of inspiration. Because the pressures on                     both sides of the Magill pressure relief valve (37)                     are equal during inspiration, the differential                     pressure provided by the “opening pressure” of the                     valve (37) keeps it dosed during inspiration.             -   (3) the volume of the inspiratory limb is greater than                 or equal to [(SGF×expiratory time)+the anatomical dead                 space]; the breathing bag volume is greater than [the                 largest expected tidal volume−(SGF×inspiratory time)],             -   (4) SGF is ≦0.7×{dot over (V)}E         -   iii) The rebreathing isocapnia circuit:             -   (1) Patient breathing spontaneously (Fisher rebreathing                 isocapnia circuit, FIG. 4). Circuit consists of a Y                 piece with patient port (58), and inspiratory limb of Y                 piece (60) with a one way inspiratory valve (59) and an                 expiratory limb of Y piece (61) with a one way                 expiratory valve (53). The inspiratory limb is connected                 to SGF (51) and a gas reservoir (52). The expiratory                 limb leads to an expiratory gas reservoir (56). The                 expiratory gas reservoir (56) has a port opening to                 atmosphere (57). Between the expiratory limb and the                 inspiratory limb, distal to the inspiratory (59) and                 expiratory (53) valves, is a bypass limb (62) that                 contains a one-way valve (54) with an opening pressure                 approximately 1.5 cm H₂O greater than the inspiratory                 (53) and expiratory (59)valves; the direction of opening                 of the one-way valve in the bypass limb (62) is from                 expiratory limb to the inspiratory limb.             -   (2) Patient ventilated: The rebreathing isocapnia                 circuit was described for spontaneously breathing                 subjects, and its use with ventilated subjects was not                 contemplated. Accordingly, to use the circuit for                 controlling {dot over (V)}A and measuring gas flux                 during controlled ventilation, we describe a new                 rebreathing isocapnia circuit suitable for use with                 mechanically ventilated subjects. Referring to FIG. 5:                 The circuit consists of a Y piece with patient port                 (58), and inspiratory limb of Y piece with a one way                 inspiratory valve (78) and an expiratory limb of Y piece                 with a one way expiratory valve (77). The inspiratory                 limb is connected to a SGF (66) and a gas reservoir                 (67). The expiratory limb leads to an expiratory gas                 reservoir (69). The expiratory gas reservoir (69) has a                 one way valve (81) at the port where expired gases are                 vented from the expired gas reservoir (71) which allows                 gas to exit the expiratory gas reservoir but not enter                 it. Between the expiratory limb and the inspiratory                 limb, distal to the inspiratory (78) and expiratory (77)                 valves is a bypass limb that contains a one-way valve                 (65) with an opening pressure of the valve approximately                 1.5 cm H₂O greater than valves in the inspiratory limb                 of the Y piece (78) and the expiratory limb of the Y                 piece (77); the direction of opening of the one-way                 valve in the bypass limb (65) is from the expiratory                 limb to the inspiratory limb. The inspiratory and                 expiratory limbs are extended by tubing of variable                 lengths, (64) and (72) respectively. The inspiratory                 (67) and expiratory (69) reservoirs are enclosed in a                 box with 3 ports: one port (79) communicates with the                 box; one port (80) communicates with the interior of the                 SGF reservoir only; one port (70) communicates with the                 expiratory gas reservoir. The SGF reservoir (67) is                 continuous with the inspiratory limb (64) of the                 circuit. The expiratory gas reservoir (69) is continuous                 with the expiratory limb of the circuit (72) and has a                 port (71) through which expired gas exits the expired                 gas reservoir and enters the box. A ventilator (73) a                 mushroom valve (74)synchronized to occlude the                 ventilator circuit expiratory port (75) during the                 inspiratory phase, is attached to the box ventilator                 port (79) such that, during the inspiratory phase, the                 tidal volume of the ventilator is discharged into the                 box (68). This will displace an equal volume from the                 gas reservoirs in the box. As the valve in the bypass                 limb (65) has a greater opening pressure than the                 inspiratory valve (78), the inspiratory reservoir (67)                 will be compressed in preference to the expiratory                 reservoir (69). When the inspiratory reservoir is                 collapsed, the remainder of the tidal volume will result                 from compression of the expiratory reservoir (69) and                 displacement of gas through the bypass limb and valve                 (65) and inspiratory valve (78) to the patient. The                 total tidal volume will be equal to the volume displaced                 from the inspiratory reservoir (67) plus the volume                 displaced from the expiratory reservoir (69) plus the                 SGF multiplied by the time during inspiration.                 -   During exhalation, balloon valve (74) is deflated,                     opening the expiratory port of the ventilator                     circuit (75) to atmosphere and the expiratory                     reservoir bag to atmosphere via port (71), thus                     allowing exhaled gas to flow past the expiratory                     one-way valve (77) down the expiratory limb (72)                     into the expiratory reservoir (69). SGF flowing into                     port (66) is directed down the inspiratory limb (64)                     to the SGF reservoir (67). Gas displaced in the box                     (68) by expansion of the SGF reservoir (67) and the                     expiratory gas reservoir (69) is displaced from the                     box via the ventilator expiratory port (75).             -   (4) SGF is less than or equal to {dot over (V)}E−{dot                 over (V)}Dan         -   iv) Non-rebreathing isocapnia circuit:             -   (1) Spontaneous ventilation (as per Fisher patent, see                 FIG. 7) The subject breathes in and out through port                 (1). Upon expiration one way valve (2) opens and allows                 expired gas to leave the circuit. Simultaneously, one                 way valve (4) is forced shut and allows fresh gas                 reservoir (3) to fill up with pressurized gas from gas                 source (5). Upon inhalation, one way valve (2) is forced                 closed and one way valve (4) is opened, drawing in fresh                 gas stored in the reservoir (3). If the volume in the                 reservoir is insufficient for a single tidal volume, the                 residual volume of the breath is drawn from demand valve                 (6), connected to a pressurized gas source of CO₂. The                 preferred concentration of this gas source is arterial                 PCO₂ to maintain isocapnia.             -   (2) Controlled ventilation (as in dog paper with Laerdal                 bag, see FIG. 8)                 -   During controlled ventilation the subject breathes                     through port (1). Non-rebreathing valve (3) forces                     expired gas through port (2). During inspiration gas                     is inspired from the self inflating bag (4) using a                     mechanical force to drive the gas through                     non-rebreathing valve (3). One way valve (5) ensures                     that all the gas within the bag is forced through                     valve (3) only. Simultaneously, fresh gas from                     pressurized source (7) fills up the fresh gas                     reservoir (6).                 -   During expiration the bag is allowed to self-inflate                     with gas stored in fresh gas reservoir. If the                     volume stored in the reservoir is insufficient for a                     single tidal volume, the residual volume of the bag                     is made up of gas drawn through low pressure valve                     (8) from a pressurized source (9), ideally                     containing arterial concentrations of CO₂ to                     maintain isocapnia.         -   iii) Balloon valve circuit             -   (1) Spontaneous ventilation (see FIG. 6)                 -   Patient breathing spontaneously (balloon isocapnia                     circuit, FIG. 6). Circuit consists of a Y piece with                     patient port (100). Inspiratory limb consists of a                     balloon valve (108), connected to SGF (109) and a                     gas reservoir (110). Expiratory limb consists of a                     balloon valve (107), leads to an expiratory gas                     reservoir (119), which has a port opening to the                     atmosphere. A tank of compressed air (106) flows                     through solenoid valves (104) to open or close                     balloon valves (108 and 107). The solenoid valves                     are controlled electronically by a computer (103).                 -   A pressure transducer (102) connected to the                     mouthpiece (101) measures when the fresh gas                     reservoir has been fully collapsed. A computer                     receiving the signal (103) sends a signal to                     solenoid valve (104) to dose inspiratory valve (108)                     and open expiratory valve (107). The fresh gas flow                     (109) continuously fills fresh gas reservoir (110).

Henceforth, all of the above circuits, under conditions suitable for measuring flux of gas using SGP, FSx, and FEx will be referred to collectively as “conditional breathing circuits, or CBC”.

For all CBC, we calculate the flux of gas x by multiplying SGF (as read from the gas flow meter as set by the anesthesiologist) by the difference between the expired gas concentration of x (FEx) and the gas concentration of x being delivered into the circuit (FSx) (which is also set by the anesthesiologist). Thus, for any gas x (other than CO₂ if a circle anesthetic circuit contains a CO₂ absorber in the circuit, see below): Flux of gas×SGF(F S x−F E x)  (1)

The advantage of using equation (1) to calculate flux, is that a) SGF is set by the anesthesiologist, is precisely known, and is constant; b) FSx is set by the anesthesiologist and is precisely known and is constant. This contrasts with the inspired concentration measured at the mouth, FIx, which may vary throughout inspiration.

Rationale for New Approach:

The principle will be illustrated with a circle circuit (see FIG. 2), but similar considerations can be made for all of the circuits and conditions outlined below.

With a patient breathing via a circle circuit, and SGF set substantially lower than {dot over (V)}E, for example one half {dot over (V)}E, only exhaled gas leaves the circuit. Therefore, at low SGF, all of the SGF can be considered “fresh gas” and will contribute to alveolar ventilation. Therefore we consider SGF={dot over (V)}A. The rest of the gas entering the alveoli is rebreathed gas. Another way of looking at this is to consider the patient to be an additional gas compartment of the circuit; we can then consider the mass balance as it applies to the circuit alone. From the perspective of the circuit, we no longer need to deal with the complex gas concentrations and flows that occur at the circuit-patient interface as in the previous art. We deal only with the gas concentrations and flows that occur with respect to gases entering and leaving the circuit. The volume of a gas entering the circuit (SGF×FSx) is equal to that of the gas eliminated from the circuit (SGF×FEX) plus that of the gas absorbed or eliminated by the patient (SGF [FSx−FEx]).

In summary, our method can be stated as: volume of gas x entering or leaving a patient=volume of gas x entering the circuit−volume of gas x leaving the circuit=SGF×FSX−SGF×FEx

Or Flux of gas x=SGF(FSx−FEx)

The prior art does not indicate that this is sufficient to calculate the uptake and elimination of gases during anesthesia and continues to require the flow-averaged concentrations of gas during inspiration and expiration measured at the patient-circuit interface, i.e., at the mouth of the patient, to calculate gas flux. This is evidenced by recent articles, for example by Wissig (2) and Rietbrock (3) which are accepted as reflecting the state of the art by an editorial in the British Journal of Anaesthesia by Bouillon and Shafer (4), the latter being recognized in the anesthesia profession as a world authority in the field of pharmacokinetics

Advantages of our Approach Over Previous Methods:

The advantages of our method in calculating the flux of a gas x would apply with the use of any circuit in which the concentration of gas x in SGF entering the circuit is known, SGP is less than or equal to {dot over (V)}E−{dot over (V)}Dan and the circuit is such that the difference between {dot over (V)}E and SGF is made up of reserve gas, the concentration of x in the reserve gas being substantially that in the alveoli at end exhalation; an example of reserve gas of suitable composition is previously exhaled gas. Examples of such circuits are the Magill circuit (Mapleson A configuration, referred to as the ‘Magill circuit’), the circle anesthetic circuit, and the rebreathing and non rebreathing isocapnia circuit (Fisher patents).

The circle anesthetic circuit is the most commonly used circuit during anesthesia. All anesthetic machines allow precise setting of SGF and its composition. Therefore, SGF and FSx are precisely known. Machines to continuously read out concentrations of such gases as CO₂, O₂, N₂O, and anesthetic vapors have been widely available for over a quarter of a century and are routinely available with all modern anesthetic systems. With our method, the flux of any gas x can be readily determined by multiplying SGP by (FSx−FEx). Oxygen and CO₂ analyzers are compact and readily available outside of the operating room. The Mapleson A circuit and the rebreathing isocapnia circuit (Fisher) are inexpensive, easy to assemble, and can be applied outside of the operating room. The method of measurement of gas flux can be applied to measuring O₂ consumption, CO₂ production, pharmacokinetics of inhaled anesthetics and other drugs, and cardiac output (the latter the subject of a separate patent application).

1) Measuring Alveolar Ventilation:

{dot over (V)}A({dot over (V)}E−{dot over (V)}Dan) is very difficult to measure for two reasons.

-   -   a) First, {dot over (V)}E is difficult to measure, To do this,         one requires a device to measure flow such as a pneumotachometer         and machine intelligence to integrate the flow signal with         respect to time and calculate volume. Whereas minute ventilation         can be calculated in mechanically ventilated subjects from         ventilator settings, it must be, measured directly in         spontaneously breathing subjects. All flow sensing devices have         drawbacks:         -   i) Pneumotachometers based on pressure differentials are             expensive and cumbersome to use outside a laboratory             setting. They are affected by changes in gas temperature and             composition; condensation from expired gas changes their             calibration and requires addition of external heaters which             introduces its own errors at high flow rates. They are also             subject to drift, in part for the reasons just given, and             require, or would benefit from, frequent recalibration.         -   ii) Electronic turbines use low resistance rotating vanes to             measure volumes. Their major drawbacks include friction and             inertia of the vane, resulting in a lag before flow is             detected and continued spin after flow has ceased         -   iii) Pitot tubes measure the pressure flowing against a             series of small tubes mounted at 90 degrees to the direction             of gas flow. They are notoriously alinear and sensitive to             changes in gas composition, as occurs during breathing.         -   iv) Hot-wire (mass flow) anemometers rely on the cooling             effect caused by laminar gas flow. However, they require             sophisticated electronics and difficult calibrations to             maintain accuracy.     -   b) Second, anatomical dead space, {dot over (V)}Dan, is         difficult to measure and estimates based on body weight are         inaccurate. Measurement of anatomical dead space requires         particular equipment and monitors and is prohibitively difficult         to do outside of a specialized laboratory.

Our method: The alveolar ventilation can be known precisely by simply reading the flow setting on the flowmeter, which is a precisely calibrated instrument. Therefore, our method

-   -   does not require the expense of pneumotachometers     -   is not affected by the inaccuracies inherent in the use of         pneumotachometers     -   circumvents the complexity of measuring minute ventilation,         integration of flow, and the requirement for precise rapid         measures of gas concentrations (see below).     -   circumvents the complexity of measuring anatomical dead space,     -   is just as accurate for spontaneously breathing subjects as it         is with ventilated subjects.

2) The previous art requires that measurements of flow be synchronized with measurements of gas concentrations in order to calculate the breath-by-breath flux of gas. The inspired gas concentration while breathing on a rebreathing circuit varies continuously throughout the breath. The net inspired volume of gas x is a flow-weighted average of the inspired gas concentration. To be able to calculate this accurately, a very rapidly responding gas analyzer and precise synchronization to the flow signal are required. This is very difficult in a laboratory setting, and even more difficult in a clinical setting. At higher flows, small errors in synchronization will give large errors in gas flux. Each error is then multiplied by the number of breaths.

-   -   With our method, only the average expired concentration of gas         is required. This allows the use of much less expensive and         slower portable gas analyzers. During any testing procedure, gas         concentrations in the gas mixture delivered to the circuit are         set by the person doing the test. When breathing through a         rebreathing circuit and when SGF limits {dot over (V)}A, gas         flux calculations are simplified to SGF×(FSx−FEx).

3) The calculation with our method is more robust and accurate that that with the prior art (see data).

-   -   a) With our method, SGF, FSx, and FEx are precisely known. With         the prior art, the errors in measuring flow, gas concentrations,         and synchronization of flow and concentration signals, are         additive.     -   b) Our method is independent of {dot over (V)}E and extent of         rebreathing. With the prior art, inaccuracy of measurement of         gas flux increases as {dot over (V)}E and the extent of         rebreathing increases.         Applications for Gas Flux Measurement:         1) Oxygen flux:     -   At present, there is no practical means to follow oxygen         consumption intra- and post-operatively in the recovery room or         intensive care area. Metabolic carts that perform this function         require the additional means to measure gas flow and complex         machine intelligence. Such machines typically cost in excess of         US$25,000 each, making it prohibitively expensive for routine         use.     -   Our method would allow continuous and intermittent measurements         of oxygen consumption in ventilated as well as spontaneously         breathing patients who are in the operating room. Outside of the         operating room, any of the CBC described above can be used to         calculate oxygen consumption by means of a simple calculation         and without the cost of additional hardware.

a) In the Operating Room

-   -   Oxygen consumption is an important index of health. Optimization         of oxygen consumption has been shown to decrease post-operative         mortality and morbidity, and improve organ function and survival         in patients undergoing intensive care after trauma, shock,         sepsis and major surgery.     -   Increases in oxygen consumption would be a very sensitive early         sign of malignant hyperthermia (MH), a rare but devastating         condition triggered by anesthesia and consisting of sudden         explosive hypermetabolism, increased oxygen consumption, CO₂         production, and high body temperature. Currently, all         anesthetized patients are monitored with temperature probes.         Increases in oxygen consumption would be a much earlier sign of         MH than increases in body temperature. Early detection and thus         early intervention would allow MH to be aborted before the         fulminant stage, averting much morbidity and saving many lives.         Furthermore, monitoring oxygen consumption with our method would         be a much less expensive than with electronic temperature probes         which are expensive and, because they have to be sterilized         between patients, have short life spans.     -   Closed circuit anesthesia provides maximum efficiency of use of         an anesthetic gas. At present, determining the O₂ flow for         closed circuit anesthesia requires “trial and error” adjustments         of the O₂ flow as indicated by the trend in the extent of         expiratory recoil of the ventilator bellows. The exact flow of         oxygen is almost impossible to ascertain and, as a result, there         is constant oscillation in the oxygen flow. The required flows         of such other gases as N₂O and anesthetic vapor are impossible         to set without knowing the total body absorption of the gas.         Attempting to set the anesthetic flow rates by trial and error         results in oscillation of anesthetic depth due to the long         delays between changes in source gas concentrations and the         development of a steady state gas concentration.     -   Knowing gas flux would allow for more accurate setting of source         gas flows, a shorter feed-back loop, and thus more stable         alveolar gas concentrations during anesthesia as well as less         frequent adjustments of source gas concentration and flow.         Patients would benefit by receiving the intended and appropriate         doses of anesthesia.     -   With our method, the O₂ flow is readily determined as the         O ₂ flow=O ₂ flux=O ₂ consumption (in steady state)=SGF×(F SO₂         −F EO₂)     -    where FSO₂ is the concentration.of O₂ in the source gas and         FEO₂ is the concentration of O₂ in expired gas.     -   Calculating flux of any gas x when breathing via a circle         circuit with low SGF and with CO₂ absorber in place         -   i) When x is CO₂, and rebreathing of CO₂ is prevented by             means of a CO₂ absorber in the circuit, equation (1) cannot             be used and one needs to know the {dot over (V)}Dan to             calculate {dot over (V)}A(as {dot over (V)}A={dot over             (V)}E−{dot over (V)}Dan). Then, CO₂ flux={dot over             (V)}A×(FECO₂−FICO₂), but since FICO₂=0, CO₂ flux={dot over             (V)}A×FECO₂. Our method does not confer any benefits to the             calculation of the flux of CO₂ when a rebreathing circuit             includes a CO₂ absorber.         -   ii) For a rebreathing circuit that includes a CO₂ absorber,             or for any CBC, and when x is any other gas:             flux_of_gas_x=SGF(F E x−F S x)+({dot over (V)}E −{dot over             (V)} D an−SGF)(F E x−F RB x)  (2)         -    where FSx is the concentration of x in the SGF entering the             circuit and FRBx is the concentration of x in the expired             limb of the circuit before the gas passes through the CO₂             absorber and mixes with gas coming out of the flowrneter.             Since F E X+F RB x,             Flux of x=SGF(F R x−F RB x)  (3)         -    Note that the actual inhaled concentration of x is the             flow-weighted average concentration of x in the mixed SGF             and rebreathed gas. However, with our method, the complex             measurement and calculation of the inhaled volume of x are             unnecessary. To measure the flux of an anesthetic, the SGF             is multiplied by the difference between the end tidal and             SGF concentrations of x. The continuous measure of flux of             any gas by this method allows one to easily calculate the             changes in anesthetic gas absorption, and hence vaporizer             setting required to maintain the same end tidal             concentrations of anesthetic for any SGF, including that             equal to O₂ consumption, which is defined as “dosed circuit”             anesthesia.

Examples of Benefits of Applying These Methods:

-   -   N₂O is an anesthetic gas used in over 95% of anesthetic         procedures. It is used in ratios of 1:1 to 2:1 with O₂. It is         relatively insoluble in blood and body tissues so that when used         as an anesthetic, the tissues saturate quickly with small         volumes of the gas and the tissue uptake of N₂O approaches 0.         Nevertheless, it is impossible with present art to know when         tissues become saturated. Therefore, N₂O flow settings are not         commonly changed throughout the operation. N₂O is an         environmental pollutant breaking down the ozone layer and costs         10 tines as much as O₂. The continued flow of N₂O at levels         greater than the rate of absorption is not only a waste of N₂O,         but also wastes the anesthetic vapor that is washed out of the         circuit with the excess N₂O.     -   Knowing the exact flux of N₂O as with our method would allow the         anesthesiologist to turn down, or off, the N₂O when the tissues         become saturated with it (i.e., when the flux=0). One would         expect that the tissues will become saturated in about 5         minutes. For a 2 hour anesthetic, this would represent a 95%         saving; the longer the operation, the greater the saving.     -   Halothane, isoflurane, sevoflurane, and desflurane are         inhalation anesthetic vapors. They have various costs ranging         from a few cents per milliliter for halothane and isoflurane to         about one dollar per meter for sevoflurane and desflurane. They         are also environmental pollutants breaking down the ozone layer.         These vapors enter the anesthetic circuits as part of SGF at         various concentrations set by the anesthesiologist. Knowing the         rate of absorption of these anesthetic vapors would allow the         most efficient use of the anesthetics and the most precise         control of the depth of anesthetic.

b) Outside the Operating Room:

-   -   With our method, a subject breathes spontaneously or is         ventilated, via a CBC as described above, oxygen consumption is         calculated as         SGF×(F S O ₂ −F E O ₂)     -   where SGF and FSO₂ are deliberately set and therefore known, and         FEO₂ is measured from a rapid O₂ analyzer.     -   Oxygen consumption in response to exercise is an important         measure of physical fitness. This is a standard test performed         routinely around the world by cardio-respiratory assessment         laboratories to test exercise capacity, cardiopulmonary fitness         and nutritional status in patients as well as in athletes.     -   Oxygen consumption is one of the measures required to measure         cardiac output by the Fick method.

FIGS. 9A, 9B, 10, and 11 illustrate flow and concentration curves for comparison to the “gold standard’ of measuring flux (timed collection) to our method.

Particularly FIGS. 9A and 9B illustrate diagrams of flow and integrated concentration curves for carbon dioxide.

FIG. 10 illustrates with 95% confidence intervals the comparison of measurements of {dot over (V)}CO ₂ for the method of the present invention and the Douglas Bag collection method and differences between those measurements.

FIG. 11 illustrates a comparison of {dot over (V)}CO ₂ for the standard bag collection method, a metabolic cart and the method of the present invention.

As many changes can be made to the various embodiments of the invention without departing from the scope thereof; it is intended that all matter contained herein be interpreted as illustrative of the invention but not in a limiting sense. 

1. A method of calculating the flux of any gas(x) in a CBC circuit for a ventilated or a spontaneous breathing subject, for example said gas(x) being; a) an anesthetic such as but limited to; i) N₂O; ii) sevoflurane; iii) isoflurane; iv) halothane; v) desflurame; or the like b) Oxygen; c) Carbon dioxide; or the like utilizing the following relationships; Flux of gas(x)=SGF(F _(SX)−F_(EX)) wherein SGF=Source of gas flow into the breathing circuit (CBC circuit) in liters/minute as read from the gas flow meter as set by the anesthesiologist; F_(SX)=Fractional concentration of gas X in the source gas (which is set by the anesthesiologist); F_(EX)=Fractional concentration of gas X in the end expired gas as determined by a portable gas analyzer, or the like.
 2. A method of calculating the flux of oxygen in a CBC circuit for a ventilated and/or spontaneous breathing subject utilizing the following relationship; Flux of oxygen=SGF(F _(SO2) −F _(EO2)) wherein SGF=Source of gas flow into the breathing circuit (CBC circuit) in liters/minute as read from the gas flow meter as set by the anesthesiologist; F_(SX)=Fractional concentration of gas O₂ in the source gas (which is set by the anesthesiologist; F_(EX)=Fractional concentration of gas O₂ in the end expired gas as determined by a portable gas analyzer, or the like.
 3. The method of claim 1 or 2 wherein the CBC circuit is selected from the group consisting of i) a circle circuit; ii) a Magill breathing circuit; iii) an isocapnia circuit, whether breathing or non-breathing (as taught by co-pending Fisher et al), or the like.
 4. The method of claim 1 or 2 wherein the CBC circuit is an improved Magill circuit as described herein.
 5. The method of claim 1 or 2 wherein the CBC circuit is an improved rebreathing circuit as described herein.
 6. The method of claim 1 or 2 wherein the CBC circuit is an improved non-rebreathing circuit as described herein.
 7. The method of claim 2 used to determine oxygen consumption in order to measure cardiac out put by any known method, such as the Fick method.
 8. The method of claim 2 used to determine oxygen consumption in, for example, an operating room setting or the like.
 9. The method of claim 2 or 8 used to optimize oxygen consumption.
 10. The method of claim 2 or 8 utilized as an early indication of malignant hyperthermia.
 11. A method of calculating the flux of any gas other than carbon dioxide, in a CBC circuit with low gas flow of source gas and with a carbon dioxide absorber in place utilizing the following relationship; Flux of gas X=SGF(FEX−FRBX) wherein SGF=Source of gas flow into the breathing circuit (CBC circuit) in liters/minute as read from the gas flow meter as set by the anesthesiologist; F_(EX)=Fractional concentration of gas X in the end expired gas as determined by a portable gas analyzer, or the like; P_(RBX)=Concentration of gas X in the expired limb of circuit before the gas passes through the carbon dioxide absorber and mixes with gas coming from the flow meter.
 12. The method of claim 11 used to determine the flux of an anesthetic for example: i) N₂O; ii) sevoflurane; iii) isoflurane; iv) halothane; v) desflurame, or the like
 13. The method of claim 12 used to determine how much anesthetic is being absorbed by the patient.
 14. The method of claim 13 wherein said anesthetic is N₂O.
 15. An improved Magill circuit the improvement comprising an inspiratory and expiratory limbs, a pressure relief valve at the end of the expiratory limb, a port for entry of SGF, and a gas reservoir bag, the components of the Magill system utilized for spontaneous ventilation; or alternatively for controlled ventilation, the gas reservoir bag is enclosed in a container with a port for connection to a ventilator breathing circuit, the pressure relief valve being enclosed in a container with a port for connection to a ventilator breathing circuit; wherein on exhalation, the patient breathes out through the patient port and during the initial part of exhalation, the gas reservoir is partially empty and the resistance to flow along the inspiratory limb is less than that of the expiratory limb because the higher opening pressure of the pressure relief valve must be overcome before flow can proceed through the expiratory limb, wherein during the initial part of expiration, the expired gas enters the inspiratory limb, displacing gas in the inspiratory limb and from the SGF into the gas reservoir, as the gas reservoir fills, the pressure in the circuit increases above the opening pressure of the pressure relief valve and the remainder of the expired gas is directed down the expired limb displacing the gas out of the expired limb through the pressure relief valve to the ventilator breathing circuit from where it is eventually vented to atmosphere through the expiratory port and the SGF continues to flow towards the patient down the inspiratory limb, displacing previously exhaled gas into the expiratory limb; wherein during inhalation, the balloon valve ocdudes the ventilator circuit expiratory port and a volume of gas equal to a tidal volume is delivered by the ventilator into the ventilator circuit and hence into the SGF gas reservoir box, thereby displacing a volume equal to the tidal volume from the SGF gas reservoir into the inspiratory limb of the Magill circuit, the SGF continues to flow towards the patient down the inspiratory limb; wherein the net tidal volume of the patient is equal to the volume displaced from the gas reservoir plus the SGF multiplied by the duration of inspiration, because the pressures on both sides of the Magill pressure relief valve are equal during inspiration, the differential pressure provided by the “opening pressure” of the valie keeps it dosed during inspiration; assuming that: (1) the volume of the inspiratory limb is greater than or equal to [(SGP×expiratory time)+the anatomical dead space]; and the breathing bag volume is greater than [the largest expected tidal volume−(SGF×inspiratory time)], (2) SGF is≦0.7×{dot over (V)}E
 16. An improved rebreathing isocapnia circuit comprising a Y piece with a patient port, and inspiratory limb of the Y piece with a one way inspiratory valve and an expiratory limb of the Y piece with a one way expiratory valve; the inspiratory limb being connected to a SGP and a gas reservoir, the expiratory limb leading to an expiratory gas reservoir, the expiratory gas reservoir having a one way valve at the port where expired gases are vented from the expired gas reservoir which allows gas to exit the expiratory gas reservoir but not enter, having disposed between the expiratory limb and the inspiratory limb distal to the inspiratory and expiratory valves a bypass limb that contains a one-way valve with an opening pressure of the valve, being for example approximately 1.5 cm H₂O, greater than the valves in the inspiratory limb of the Y piece and the expiratory limb of the Y piece; the direction of opening of the one-way valve in the bypass limb being from the expiratory limb to the inspiratory limb, the inspiratory and expiratory limbs being extended by tubing of variable lengths, the inspiratory and expiratory reservoirs being enclosed in a box with 3 ports; one port communicates with the box, one port communicates with the interior of the SGF reservoir only, one port communicates with the expiratory gas reservoir, the SGF reservoir is continuous with the inspiratory limb of the circuit, the expiratory gas reservoir is continuous with the expiratory limb of the circuit and has a port through which expired gas exits the expired gas reservoir and enters the box, a ventilator, a mushroom valve synchronized to occlude the ventilator circuit expiratory port during the inspiratory phase attached to the box ventilator port such that during the inspiratory phase, the tidal volume of the ventilator is discharged into the box, which will displace an equal volume from the gas reservoirs in the box; as the valve in the bypass limb has a greater opening pressure than the inspiratory valve, the inspiratory reservoir will be compressed in preference to the expiratory reservoir, when the inspiratory reservoir is collapsed, the remainder of the tidal volume will result from compression of the expiratory reservoir and displacement of gas through the bypass limb and valve and inspiratory valve to the patient, the total tidal volume will be equal to the volume displaced from the inspiratory reservoir plus the volume displaced from the expiratory reservoir plus the SGF multiplied by the time during inspiration; during exhalation, the balloon valve is deflated, opening the expiratory port of the ventilator circuit to atmosphere and the expiratory reservoir bag to atmosphere via the port, thus allowing exhaled gas to flow past the expiratory one-way valve down the expiratory limb into the expiratory reservoir, SGP flowing into the port being directed down the inspiratory limb to the SGF reservoir, wherein gas is displaced in the box by expansion of the SGP reservoir and the expiratory gas reservoir is displaced from the box via the ventilator expiratory port; wherein SGF is less than or equal to {dot over (V)}E−{dot over (V)}Dan.
 17. An improved non-rebreathing circuit, the improvement comprising a balloon valve circuit for spontaneous ventilation of a patient breathing spontaneously, said circuit having a Y piece with a patient port, an inspiratory limb including a balloon valve; connected to SGF and a gas reservoir, an expiratory limb consisting of a balloon valve leading to an expiratory gas reservoir, which has a port opening to the atmosphere, a tank of compressed air flows through solenoid valves to open or dose the balloon valves, the solenoid valves being controlled electronically by a computer, a pressure transducer connected to a mouthpiece for measuring when the fresh gas reservoir has been fully collapsed, the computer for receiving the signal and sending a signal to the solenoid valve to close the inspiratory valve and open the expiratory valve, the fresh gas flow continuously filling the fresh gas reservoir.
 18. The method of claims 1, 2, or 11 used to calculate the rate of elimination of a gas X for any input total gas flow utilizing the following further relationships; wherein the rate of elimination of gas X=the input total gas flow (multiplied by) F_(EX)−FI_(X); wherein F_(EX) is defined above and F_(IS) is the concentration of X in inspired gas.
 19. The method of any previous claim wherein said method is incorporated in an algorithm spreadsheet, formula or the like contained within software which is capable of running on a computing device, or is installed therein. 